To view the abstract for a session, click its title;
to hide the abstract, click the title again.

•

To search by keyword or author, use your
browser's Edit > Find command.

APM is Going Green — the Academy is conscious of our "carbon footprint" and will not be printing abstracts for the meeting.

To print your own copy of the abstracts from this web page, first display all the abstracts you want to print by clicking the papers' titles, and then use your browser's Print command.

To print an abstract without printing the entire web page, after displaying the desired abstract by clicking its title, use your browser's File > Print Preview command, find the page number(s) that display the abstract, and print only those page(s).

Medical comorbidity is common among psychiatric patients. However, there has been long-standing concern about the quality of medical care offered to people with mental illnesses as multiple studies have demonstrated a higher level of functional and occupational disability, poorer quality of life, and accelerated mortality among people with mental illnesses than those without. In order to close the medical care gap in people with mental illnesses, several models of integrated medical and psychiatric services have been proposed and tested in different healthcare settings.

In this symposium, each presenter will describe the current efforts to integrate psychiatric care in different medical settings. Dr. Lee will describe the impact of the Behavioral Intervention Team, a proactive psychiatric consultation service that screens and delivers psychiatric assessment and care for every medical patient admitted to Yale New Haven Hospital. Dr. von Esenwein will discuss the efforts to improve primary medical care in community mental health settings through medical care management based on the Primary Care Access, Referral, and Evaluation (PCARE) Study as well as a more recent study on utilizing electronic personal health records to abridge the fragmented services for people with severe mental illnesses (the MyHealthRecord study). Dr. Lyketsos will describe the J-CHIP model that aims to transform the health of the East Baltimore community through "augmented" or "intensive" primary care to high risk patients and trans-disciplinary care coordination for acute care patients. Finally, Dr. Druss will discuss the common components across the three models while pointing out the unique features that meet the needs of the target populations in the different healthcare settings. He will also discuss the future of the integrative healthcare services in the context of changing health care environments.

Objectives:

Audience will recognize the need for integration of medical and psychiaitric service in the current health care system.

Audience will recognize how each of the three proposed models aims to integrate psychiatric and medical services in different medical service settings (inpatient vs. outpatient)

Audience will understand the changing roles of mental health service provided in different models of integrated medical and mental health services.

Relevance:
As we face health care reform, integration of medical and psychiatric care setting becomes critical. This symposium examines three different models of service integration that has impact on C-L psychiatry.

Limbic Encephalitis
Limbic encephalitis (LE) was once thought to be rare but recent studies have found surprisingly high rates of LE, particularly the non-paraneoplastic variant. LE can be challenging to diagnose given the wide spectrum of physical, neurological, and psychiatric symptoms produced, however, studies such as MRI, EEG, CSF analysis, and antibody panels can be helpful. A wide range of auto-neuronal antibodies have been discovered which target plasma membrane, cytosolic, and extracellular antigens of both the central and peripheral nervous system. Diverse mechanisms of antibody production can lead to variable response rates to immunosuppressive treatments such as IVIG, steroids, rituximab, plasmapheresis, and cyclophosphamide. Improving treatment efficacy will require identification of, as yet, unknown auto-antibodies and a deeper understanding of mechanisms by which auto-antigens are attacked.

Neuropsychiatric Complications of HIV/AIDS
The HIV/AIDS epidemic is now entering its third decade, and great strides have been made in controlling the virus in the human body. CNS pathology continues to present itself in those with uncontrolled virus, but also in those who have achieved and maintained undetectable viral loads. Patient symptoms may range from obvious focal deficits to subtle neurocognitive changes. This presentation will review the latest findings in HIV-related CNS clinical pathology, diagnosis, and treatment.

CNS Malignancies
With continued advances made in cancer treatment, patient suffering from primary or metastatic CNS disease are living longer and encountering various neuropsychiatric complications. Dr. Kilbane will review the various ways (e.g., lesion location, treatment side effects, psychiatric co-morbidity, "chemo-brain") in which CNS malignancies can alter neuropsychiatric functioning. He will also review current strategies to ameliorate these negative effects.

Non-Convulsive Status as Cause for Delirium and Mental Status Changes
Non-Convulsive Status Epilepticus (NCSE) is characterized as a change in mental processes and behaviour in association with continuous epileptiform changes on the electroencephalogram without major motor signs (Epstein et al, 2009). It may present as delirium, but its diagnosis is often delayed and even missed. In the critically ill patients, it is associated with high rates of morbidity and mortality. For example, in one study of patients with altered mentation and identified NCSE, there was 52% mortality rate, while higher amounts of antiepileptic drugs did not improve outcome and treatment with benzodiazepines was actually associated with increased risk of death (Litt et al, 1998). In this presentation, Dr. Sher will discuss epidemiology and various presentations of NCSE, focusing on this entity as a differential diagnosis for delirium. We will also address its proper diagnosis, prognosis, and treatment. As psychosomatic physicians, we should be aware of this neurologic emergency masquerading as delirium, but often overlooked and not properly addressed.

Objectives:

Attendees will be familiar with the variety of neuropsychiatric “insults” inherent to CNS malignancies and infectious agents- and their treatment.

Understand the effects of HIV and comorbid disorders (including opportunistic infections and common substances of abuse) in the central nervous system.

Understand the epidemiology, manifestations and improve the recognition of NCSE among medically ill patients.

Relevance:
This symposium will focus on a number of neuropsychiatric conditions presenting with medically unexplained, behavioral or cognitive symptoms for which PM consultations are often called for evaluation and management.

Fiscal Viability of Training in Psychosomatic Medicine: Cost, Reimbursement, and Value in an Era of Health Care Reform

Models for the payment of health care services and the organization of primary and specialty care services are undergoing reorganization. Legislative bodies are attempting to change how funding for health care is distributed in an effort to align provider incentives with stated legislative goals. As is the case with other disciplines, the field of psychosomatic medicine will need to respond to these impending changes in such a way that excellence is maintained in patient care and outcomes, services that are provided are considered to be useful by primary medical/surgical services, and fiscal viability is maintained. This symposium aims to examine psychosomatic medicine's place at the intersection of changing models of health care and funding, the ethical implications of changing practice in response to changes in the larger health care system, and how these changes will impact practice and training in psychosomatic medicine.

Models that integrate behavioral health care both in primary care and in specialty medical settings have proven effective in increasing access to psychiatric services and in treating psychiatric disorders. Nationally, recent policy changes such as the Affordable Care Act and the emergence of related clinical care models such as the Patient Centered Medical Home have also set the stage for more widespread implementation of integrated models of care. Collaborative care is the integrated model with the strongest empirical support, however, little information is available on the practical daily experience of psychiatrists providing effective collaborative care when such a model is implemented in real-world settings.

This workshop offers an opportunity to better understand the daily experience of consulting psychiatrists within a statewide collaborative program, the Mental Health Integration Program (MHIP) in Washington state. MHIP, based on the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) model, has provided behavioral health treatment for more than 20,000 patients in over 100 safety-net community health centers since 2008. In this workshop, we will teach and discuss the “nuts and bolts” of working with a care manager and review what it means to provide stepped care to a population of patients by demonstrating the effective use of patient registries and the application of treat-to-target principles. We will also review the nature of risk management in a collaborative system where much of the psychiatrist’s patient care services are provided indirectly. The workshop will emphasize how the psychiatrist’s role as a caseload consultant in an integrated primary-care based model is similar to and different from traditional specialty psychiatric practice and how the skills of consultation-liaison psychiatry are utilized in this role. To facilitate an interactive environment, we present brief formal presentations, incorporate role-play of the care manager-psychiatrist consultation, and case-based discussions along with open Q and A sessions.

This is the second collaborative effort for the Academy of Psychosomatic Medicine (APM) and the American Association for Emergency Psychiatry (AAEP). Most primary care providers are not prepared to handle emergent psychiatric conditions in their office and the emergency department (ED) has become the primary portal for entry into the mental health system. Few community hospital EDs have dedicated psychiatric ED staff so psychosomatic medicine (PM) specialists are often the clinicians called emergently to care for this highly complex population. The PM physician must coordinate acute psychiatric needs with medical primary care providers or assume responsibility for ultimate disposition, all while assessing and treating acute presentations. Since the disposition process is tedious, the acutely agitated patient can quickly overwhelm ED staff. We will review the care for this critical clinical situation and present the findings of AAEP’s Project BETA: Best Practices in the Treatment of Agitation.

Psychiatric Evaluation of the Agitated Patient
Assessment of agitated patients is difficult; The complete psychiatric evaluation usually cannot be completed until the patient is calm enough to participate in a psychiatric interview. We will review a two step consensus process from the AAEP to reach this goal safely and effectively.

Psychopharmacologic Interventions for Acute Agitation in the ED
We will review interventions for treatment of these patients based upon presentation and differential diagnosis. We will present the Project BETA guidelines for acute intoxication, delirium, and idiopathic conditions. A rapid algorithmic approach will be proposed with interventions guided by accurate and prompt assessment of likely causes of agitated states.

Effective Interventions in Childhood Agitation
More and more children are being diagnosed with acute psychiatric conditions. The agitated child presents clinical, ethical and practical dilemmas for clinicians. Few EDs are equipped to intervene in this challenging population. We will review current strategies for interventions.

Medical Clearance
How to determine if a patient is “medically clear”? We will review elements of a history, physical, and laboratory testing pertinent for this determination. We will discuss how the Psychosomatic clinician can better collaborate with treating physician.

Objectives:

Be able to discuss three pharmacologic and behavior interventions that can be safely used in the agitated emergency department patient.

Discuss two reasons why a child may present to the emergency department in an agitated state

Be able to explain Emergency Medicine’s perspective on “medical clearance” of psychiatric patients

Relevance:
Psychosomatic Medicine provide emergency psychiatric care for general emergency departments in most settings. Emergency and crisis interventions are complex, require detailed colloboration, and the outcome is never predetermined.

Perinatal psychiatric illness is common[1] and carries significant morbidity and mortality for mother, fetus/child and family.[2,3] Perinatal psychiatric illness may impair women's judgment, self-care, and decision making, giving rise to sensitive and complex legal and ethical issues around psychiatric, obstetrical, and neonatal care.[5,6] Such situations often present unchartered challenges for women, their families, and their medical providers.

Drs. Dresner and Byatt will lead an interactive discussion with the audience and panelists (Drs. Roberts and Brendel) in which we will discuss complex cases and the various ways they can be approached from a legal and ethical standpoint. Drs. Gramann, Forrester, Becker, Kurzman, and Meltzer-Brody will each present a case that illustrates the following complex legal and ethical issues:

Assessment of decisional capacity to terminate pregnancy in women with chronic mental illness

Informed consent to prescribe psychotropic medications in pregnancy

Assessing suicide risk in the context of bereavement over fetal loss

Complex legal and ethical issues that arise during fertility treatments

During the interactive discussion, Drs. Byatt and Dresner will share their experiences and expertise in working with perinatal women, and Drs. Roberts and Brendel will provide an overview of the legal and ethical principles involved in managing each case.

This interactive workshop will include a number of brief presentations about clinically recent and important research developments in different areas of research relevant to the practice of CL Psychiatry. The reviews will be presented by an active researcher in the field. After each presentation, there will be ample time for the participants at the workshop to ask questions about the nature of the new evidence presented and its implications for their clinical practice.

Objectives:

Be aware of recent research developments in specific areas of C-L practice.

Have the ability to critically appraise recent research.

Understand the implications of recent research for specific areas of C-L practice.

Relevance:
This workshop will update participants on the recent research that underpins their clinical practice; how to appraise it, and what its implications are.

This highly interactive workshop is designed to provide early career psychiatrists with tools to cope with common and highly distressing "adverse events" in the practice of psychosomatic medicine (PM). Three two-person teams of presenters (an early career psychiatrist paired with an experienced PM clinician/educator/administrator) will address three challenging professional developmental crises: 1) being the recipient of patient complaints, 2) workplace violence, and 3) the suicide of a patient.

Each early career psychiatrist will briefly present one case from these three categories and describe their reactions and questions that stemmed from their experiences. After each case presentation, the senior member of the team will briefly comment on practical, emotional, clinical, and administrative implications of the case derived from the published literature and their professional experience.

As part of each case, there will be a generous discussion period when the audience will be invited to share similar experiences and strategies to cope with and learn from these difficult and unavoidable aspects of PM.

Objectives:

Understand the risk for professional crises in psychosomatic medicine and how this affects early career psychiatrist career development.

Learn practical strategies for the management of common adverse events in the practice of psychosomatic medicine.

Consider novel ways to help manage the distress associated with these adverse events at all stages of one’s career.

Websites, blogs, eBooks, and interactive PDFs are just some of the technologies being used by medical educators to augment or replace traditional psychiatric teaching. While many educators would like to be able to use technology to diversify the formats through which they engage students, educators are often intimidated by the technologies involved in creating these products. This workshop will offer both technology novices and experts ideas that they can incorporate into their own teaching. An emphasis will be placed on "Do-It-Yourself" projects with a low price-point.

Panelists will share stories of how readily available technologies were used to create novel educational activities, with an emphasis on the pros, cons, and lessons learned from each project.

Dr. Gorrindo, co-director of the MGH Psychiatry Academy, will discuss the creation of an interactive video PDF used to train faculty on the child and adolescent psychiatry Clinical Skills Verification (CSV) exam. Using the Adobe PDF "form" feature and video clips created by the AADPRT Child CSV Task Force, this interactive document trained faculty on the basics of the CSV, allowed them to practice scoring video cases, compared faculty responses to a panel of experts, and increased inter-rater reliability across faculty.

Dr. Dingle, associate professor and program director of child/adolescent psychiatry training at Emory, will discuss the creation of an online ethics resource center for the American Academy of Child and Adolescent Psychiatry (AACAP). She will also highlight the use of a public blog and a web-based "Ask the Expert" column as part of an online engagement strategy to increase awareness about ethics and the AACAP ethics resource center.

Dr. Boland, professor of Psychiatry and Human Behavior at Brown, will discuss the power of Google Docs, specifically focusing on the use of "Google forms" for managing CME feedback, coordinating faculty evaluations, and completing self-assessment activities.

Dr. Stern, director of the Avery D. Weisman Psychiatric Consultation Service at MGH and professor of Psychiatry, Harvard Medical School) will discuss the process of self-publishing a book using electronic (iBook, Kindle, Nook) and print-on-demand formats. He will highlight the differences between working with a traditional publisher and self-publishing, and will discuss the editorial process of creating an e-book.

Then, participants will present their own educational dilemmas that they hope to solve with technology. Participants will join either a "technology beginners" group or a "technology experts" group. Through the use of handouts and facilitated discussion by technology and educational experts, participants will clarify learning objectives, identify appropriate technologies, and outline next-steps for their own projects.

Objectives:

Learners will be familiar with new uses of technology in the educational setting.

Learners will be able to apply technology to their own educational dilemmas.

Learners will analyze the strengths and weaknesses of applying various technologies to their own educational dilemmas.

Relevance:
While educators would like to use technology to diversify the formats through which they engage students, educators often feel intimidated by the technologies involved in creating educational products.

Use and abuse of benzodiazepines remains a controversial issue in psychiatry and medicine. Increasing concerns about prescription drug abuse and polypharmacy have furthered these controversies. Wide variations are noted when practitioners are surveyed with regard to whether they prescribe benzodiazepines, which diagnoses benzodiazepines are prescribed for and choice as well as dosage of benzodiazepine. A workgroup was recently established at our medical center to review these issues. It had been noted that in a group of over 60 mental health division practitioners there was a large variation in the numbers of patients prescribed benzodiazepines as well as the choice of medication. The objectives of the workgroup were: 1) review the literature to identify best practices with regard to benzodiazepine prescribing and to identify high-risk populations; 2) Once “best practices” were identified, draft and disseminate guidelines for appropriate use of benzodiazepines.

This workshop will review the history and pharmacology of benzodiazepines and traditional prescribing practices. The results of our review, including diagnostic considerations, choice of benzodiazepine, combination with other medications and medical marijuana and detoxification, will then be addressed. A summary of our guidelines and recommendations for benzodiazepine use will be presented. We will then facilitate a discussion of cases from our own and the audience’s experience.

At the end of this presentation the learner will be able to describe the history of benzodiazepine use and concerns regarding abuse and dependence on benzodiazepines.

At the end of the presentation the learner will be able to discuss the diagnostic indications and contraindications for benzodiazepine use.

At the end of the presentation the learner will be able to describe an appropriate approach for discontinuation of benzodiazepines.

Relevance:
Benzodiazepines are frequently prescribed in primary care for anxiety and insomnia. Prescription drug abuse is a major public health concern; C-L psychiatrists are frequently consulted to assist in these cases.

While the ethical framework for transplantation candidacy is based on the concept of equal access for all patients to potential medical benefit, a limited supply of donor organs necessitates allocation consideration based on relative capacity for a good outcome among potential candidates. Effective informed consent and reliable adherence to a complex medication regime are essential in a successful transplantation. However, psychiatric co-morbidities could potentially compromise a successful transplant outcome and present an ethical conflict for the evaluating psychiatrist during the psychosocial assessment for organ transplant candidacy.

This symposium highlights the ethical dilemma posed by three common psychiatric comorbidities among transplant candidates: substance abuse, severe mental disorders, and cognitive impairment. Dr. DiMartini will discuss ethical dilemmas in liver transplantation for patients with alcoholic cirrhosis and how her recent research and review of literature guides her assessment. She will also address the issues related to the recent controversy over transplanting patients with acute alcoholic hepatitis. Dr. Shapiro will discuss ethical issues in consideration of organ transplant candidacy for patients with severe mental disorders such as schizophrenia and bipolar disorder. Dr. Lee will discuss the recent trend of increasing number of transplants among the elderly and will discuss the impact of advanced age on transplantation outcomes and the emerging ethical dilemma in transplantation for elderly patients with cognitive impairment. Finally, Dr. Wolpe will review bioethical principles that could provide a conceptual framework in approaching these ethical dilemmas posed by psychiatric comorbidities.

Objectives:

The audience will identify the three common ethical dilemmas encountered during the evaluation of pre-transplant candidates.

The audience will explain current evidence relevant to the ethical dilemma posed by psychiatric comorbidities such as substance abuse, cognitive impairment and severe mental illnesses.

The audience will apply ethical principles in evaluation of ethical dilmmas faced during the pre-transplant psychiatric evaluation of organ transplant candiates.

While the days of women in medicine being a novelty is a thing of the past, more and more female physicians are facing the challenge of raising a family while working in a very demanding field. As a result often times physicians are waiting until the end of training to start their families.

Many have done it before and can offer advice about how they handled the challenges, but roles and always changing and evolving; what worked for one generation may not work for another. This certainly raises challenges for those early career psychosomatic practitioners who opt to raise a family while working in this subspecialty.

Within the field of psychiatry, psychosomatic medicine is certainly considered to be very intense work with the potential for long, unpredictable work hours. This has been the sole reason some psychiatrists opt not to work in psychosomatic medicine, despite having clear passion for this work.

This workshop will focus on the specific obstacles that parents face, and morever will show that there are many ways that practitioners can have the best of both worlds. We hope to further delineate the modern challenges that impact our colleagues and provide some insight into how things have changed or remarkably stayed the same. At the end of the presentation interactive discussion with the audience will take place.

There is evidence that domestic circumstances influence women's medical career and that this is an impact on the probability that women will marry and/or have children. Several studies have found that female graduates make their career choice based on their future desire to have a family. Women with children face more career obstacles in academic careers and less institutional support.

Work-life balanced have been studied in several countries such as Japan, Germany and Switzerland. In this workshop we will make a parallel comparing the available data in different countries. We will also present the results of a study done in Colombia, South America. This study included 50 female psychiatrist who work in private and academic institutions. It was found that 75% of these psychiatrists worked full-time , 70% had children, and 45% were divorced. They also found that 70% of women felt that their careers had a negative impact on their families.

Dr. Falcone will talk about managing schedules and negotiation with colleagues.

As part of the ACGME requirements for accreditation of fellowship training programs, program directors are expected to use competency-based assessment tools to evaluate their fellows and provide them with constructive feedback. Based on the ACGME core competencies for Psychosomatic Medicine, the APM Fellowship Training Subcommittee, led by Dr. Crone, developed a competency-based assessment tool, “Clinical Vignettes”, to assist program directors in the task of evaluating fellows and maintaining their accreditation. The Clinical Vignettes were introduced in 2011 on the APM website for the use of program directors. This workshop will provide a formal introduction to the Clinical Vignettes and will discuss how they can be used for fellowship training.

The 22 vignettes were designed to be interactive between teacher and learner and to span a wide spectrum of clinical conditions or situations that the PM clinician is likely to encounter. Each vignette is presented to the fellow, who is expected to ask questions, develop a differential diagnosis, and recommend treatment for the condition described.

Each vignette includes a list of items that the fellow must address to achieve mastery. In addition, many contain additional items that, if identified, suggest a higher level of competence in a particular area. Thus, it is easy to identify weaknesses and strengths in each fellow and to develop a strategy for improvement if necessary. Each vignette also includes up-to-date references for further study and enrichment.

This workshop will include:

Update on ACGME requirements for evaluation of fellows (Dr. Desan)

Introduction to the Clinical Vignettes

History of development (Dr. Crone)

Format, administration, and scoring (Dr. Rabinowitz)

Different uses (Drs. Desan and Becker)

Standardized tool for evaluation of Fellows

Didactic tool, to teach fellows; to teach fellows to teach residents and medical students

Demonstration
Volunteer PM fellows (Drs. Trenton and Mosier) will be examined by PM faculty Drs. Stern and Becker using the vignettes, with real-time feedback.

Discussion (faculty/audience)

How are participants’ programs using the vignettes?
Results of PM Director’s Survey (Drs. Bronson and Joseph)

Other uses for vignettes in Fellowship programs

Ideas/topics for other vignettes

Critique of vignettes

Objectives:

Describe how to access and understand how to use the Clinical Vignettes for training fellows in psychosomatic medicine.

Identify specific ACGME requirements that can be met by using the Clinical Vignettes for fellow training.

Develop other clinical vignettes using the schema described in the Workshop.

Relevance:
Fellowship training in psychosomatic medicine is a critical component of psychosomatic medicine. Clinical vignettes will be an important new component in fellowship education with the new ACGME requirements.

Clinicians practicing psychosomatic medicine face ethical issues on a daily basis. Many of us are asked to render our professional opinion regarding capacity assessment, others are official members of the hospital Ethics Committee, yet others are asked to provide opinions which may significantly alter the course of the patient's treatment and outcome. In this workshop we are going to discuss three clinical cases involving complex ethical dilemmas and practical ways to handle the day to day practice.

Case 1: Heartache and existential pain in an LVAD patient — Dr. Sher will introduce the case of a young man suffering from end-stage heart failure asked to be evaluated by psychiatry for ventricular assistive device (VAD) implantation, found to be depressed and hypoactively delirious. During the evaluation and treatment, patient had a very difficult time making a decision regarding VAD torn between his values in life, expected and desired quality of life versus the wishes of his family and recommendations of the physicians. We will discuss the ethical aspects of determining patient's capacity to make this very challenging life-and-death decision as well as the role of the psychiatric consultants to assist such a patient in arriving at the right decision for him.

Case 2: When the physician is the one dying — Dr. Kilbane will discuss the case of a young urologist, admitted with altered mental status in the context of recently diagnosed glioblastoma multiforme and seizure activity with associated fall and subsequent bilateral frontal subdural bleeds. The O/P clinicians expressed expectation for improvement and offered further chemotherapy "once his delirium improves". His agitated behavior eventually evolved into terminal delirium and return to baseline cognitive functioning was not expected. Ethical issues illustrated included supporting the patients advanced directives as they were in conflict with what family members wanted (autonomy), ensuring comfort at end of life (beneficence), minimization of further physical/psychic pain (non-maleficence), consideration of resource allocation (justice), and transition to palliative and hospice care.

Case 3: Is honoring a depressed, suicidal patient's wish a form of physician assisted suicide? — Dr. Maldonado will discuss the case of a depressed patient who attempted to commit suicide by jumping off a cliff. After having being saved and operated on she was prematurely extubated. When the ICU team attempted to re-intubate her, she declined and insisted she wanted to be DNI/DNR. We will discuss issues of capacity, autonomy, and non-maleficence, and how they relate to the issue of professional integrity, compassion, and evidence-based care.

Discussion: Dr. Roberts, a national expert on medical ethics, will serve as discussant for this event and the complexities raised by the cases discussed.

Objectives:

Identify appropriate patients for EMR work, major pitfalls to avoid, basic steps of the trauma theatre, and how to follow-up with future-pacing hypnotherapy.

Identify at least 3 specific ways that mindfulness could be incorporated into or supplement their PM work, and be able to make relevant referrals.

Understand the basic procedures in the application of hypnosis-based techniques and their application in PM work.

Relevance:
PM patients present with a variety of symptoms (e.g., chronic pain, PTSD, somatization) that may respond very well to non-pharmacological interventions, as an alternative and/or supplement to well-established pharmacological treatments.

American healthcare is in a state of substantial change driven by concerns over the cost, quality, and the payment model. While the final forms of these multidimensional changes are far from settled, this is a period of significant activity and opportunity for those concerned with integrated medical and psychiatric care.

This symposium will discuss the importance of organization-based national initiatives in fostering new psychiatric integrated models of care with the goal of meeting the "triple aim" of health reform including: improving access to care, improving quality and outcomes of care, and reducing total health care costs. Dr. Summergrad will describe work by the American Psychiatric Association's Ad Hoc Committee on Healthcare Reform, which is evaluating the changing role for psychiatrists in a health care reform environment. Dr. Druss, a member of the Committee, will share clinical, research, and policy development about the effectiveness and dissemination of new models of care that integrate medical care into community mental health systems for patients with severe mental illness. Dr. Katon, also a member of the Committee, and the chair of a similar committee for the APM, will discuss the psychiatrist's role in an update of the collaborative care model in which psychiatrists work with primary care physicians to provide care to large populations. Dr. Kathol will share developments of integrated care committees at the National Integration Academy Council (NIAC-AHRQ) and the Center for Integrated Health Solutions (CIHS-SAMHSA/HRSA) including the development of an integrated care lexicon that contains core principles in the delivery of outcome changing medical and mental health care.

These four presentations will review the limitations of current models of care, including societal ethical concerns regarding large numbers of patients who cannot access quality mental health care or primary care. The presentations will review what we know about integrated care models and how participation in national organization-based initiatives can be used to foster needed educational and work force change for adoption of new models that improve the quality of care to all, but especially to those with marked healthcare disparities.

Objectives:

To learn about strategic initiatives of APA and APM committess on integrated care.

To learn about multicondition collaborative care models.

To learn about models that integrate medical care into community mental health centers.

Relevance:
This presentation will help members learn about strategic intitiatives and models to help psychiatrists meet the challenge of health reform.

Not infrequently, individuals present to the general medical hospital with atypical disturbances of cognition, comportment, and motion that lead medical specialists to the reflexive conclusion: "This is psychiatric." Previously-made psychiatric diagnoses may be used erroneously to justify this conclusion, and then to excuse the subsequent tendency: the physician holds up his hands, halts medical testing, calls psychiatry and demands the patient be transferred to a psychiatric unit. In the face of such demands, psychiatrists must be able to administer a focused physical examination, maneuver laboratory studies and imaging, understand neural underpinnings of behavior, and deliberate on the most appropriate management for each patient. The timid psychiatrist is comfortable riding recklessly in the back seat; the competent psychiatrist must steer the treatment team (and the patient) to safety.

Amid recommendations by the American Psychiatric Association and Academy of Psychosomatic Medicine to include a physical exam as part of every psychiatric assessment, comfort with objective clinical findings is imperative. Using clinical cases, videos, and simulated examples, this symposium will revisit physical findings associated with the following conditions: (a) Toxidromes and Medication Effects (e.g., serotonin syndrome), (b) Metabolic and Endocrine Disorders (e.g., Wilson's disease), (c) Neurologic Illness (e.g., frontal network syndromes), and (d) Psychiatric Disease (e.g., conversion disorder).

Objectives:

Reinforce knowledge of physical findings germane to the practice of psychosomatic medicine.

Incorporate a focused physical exam into each psychiatric evaluation completed in the general medical setting.

Relevance:
As clinical providers at the interface of psychiatry and general medicine, we all benefit from a solid foundation in interpreting physical findings associated with disturbances of affect, behavior, and cognition.

With the obesity epidemic reaching epic proportions in North America and high prevalence of obesity in psychiatric patient populations, psychiatrists are now considered integral to the management of severe obesity in hospital and community-based settings. Psychosomatic medicine clinicians are in a unique position to provide much needed multi-modal psychosocial approach to individuals suffering from severe obesity due to their skills in managing complex psychiatric and obesity-related medical comorbidities.

Rates of childhood obesity have increased over the last decade and identification of early childhood factors, such as dysfunctional family dynamics, trauma and early eating psychopathology, can be helpful in early obesity management. Obesity is frequently perpetuated in adult life by environmental, relationship, medical and psychological factors that may be amendable to psychiatric treatment. Comprehensive psychiatric assessment can be instrumental in identifying key psychiatric variables contributing to obesity through exploration of nutritional, metabolic and physical activity pathways. Further, treatment of common psychiatric disorders in obese patients may be needed to facilitate and sustain weight loss. Weight loss surgery (bariatric surgery) is a recommended treatment for severe obesity and requires psychiatric involvement to determine risk, anticipate post-operative complications and to improve long-term surgical outcomes. Unfortunately, massive weight loss has been associated with emerging body image concerns and disordered eating, and requires more attention to psychosocial interventions post-bariatric surgery.

The symposium will explore psychiatric causes of severe obesity across the lifespan and the role of psychiatrists in the management of obesity and comorbid psychiatric factors. Dr. Shaligram will discuss early childhood causes of obesity and the evidence for early intervention. Dr. Micula-Gondek will provide a psychiatric approach to the assessment and management of bariatric surgery candidates in the peri-operative phase. Dr. Hawa will discuss the long-term eating disorders and body image issues associated with massive weight loss and potential psychiatric treatments for these complications. Lastly, Dr. Sockalingam will summarize evidence on psychosocial interventions improving weight loss and psychosocial outcomes post-bariatric surgery. Data from the University of Toronto Bariatric Surgery Collaborative will be used to supplement the evidence for psychosocial interventions. Cases and an illustrative patient video will be used to highlight the above concepts.

Objectives:

Recognize predisposing psychosocial factors to obesity in early childhood.

Apply a psychiatric approach to managing bariatric surgery patients in the peri-operative phase.

Relevance:
Psychosomatic medicine clinicians will learn a multi-modal psychosocial approach to individuals suffering from severe obesity due to their skills in managing complex psychiatric and obesity-related medical comorbidities.

Psychiatric consultants are increasingly being asked to provide information relevant to complex ethical, clinical, social, and legal decisions that may result in accelerating patient deaths. These requests reflect a quiet revolution that has occurred in medical practice over the past three decades. While it was previously considered improper to discuss death with patients and families, nowadays physicians and nurses are being encouraged and even legislated to have such conversations. Those practitioners who share the philosophical tenets of palliative medicine believe that our society approves of efforts to limit or curtail suffering - even if death is hastened. They hold that deaths following administration of analgesic medications and decisions to withhold or withdraw life-sustaining treatments are distinctly different from those resulting from murder or clinical suicides (involving depressed or psychotic people).

Over one million Americans die each year while receiving hospice and palliative care services, and this number is propelled by the concept that good deaths allow for maximum autonomy, symptom management, and sufficient time for preparation, reconciliation, and communication with family and loved-ones. The same ideal underlies an increasingly active Death with Dignity Movement that has led to legalization of physician-assisted dying/suicide in Oregon, Washington, and Montana, and has prompted a November 2012 ballot initiative in Massachusetts.

The practice of medicine is evolving and today's doctors are actively being recast in new and multifaceted roles. This symposium is optimistically grounded in the Reverend Martin Luther King's aphorism, "There comes a time when time itself is ready for a change." It is designed with the intention of preparing psychiatric consultants to continue responding to these changes and begin a reconsideration of how to respond to end-of-life issues and assisted suicide.

Dr. Cohen will show a brief clip from the award-winning documentary, "How to Die in Oregon," and recount the story of the oncology surgeon who participated in the film.

Dr. Hails will review the history of assisted suicides beginning with the Greeks, and examine the Hippocratic Oath, the rise of Christianity, and changing views about the "sanctity" of life.

Dr. Brendel will delineate the legal and constitutional framework for end-of-life decision-making through a review and discussion of landmark U.S. Supreme Court cases.

Dr. Fischel will present a case report that highlights the intricacies of assessing a patient's capacity to request DNR status when there is a question of suicidal intent.

Dr. Bostwick will describe different ethical standards for decision-making in a patient a) whose condition affords a life-extending treatment option; b) who is alive as the result of having chosen such an option; or c) whose condition is truly terminal in the absence of treatments to extend life beyond an otherwise "natural" death.

Objectives:

Participants will understand the historical shifts regarding physicians assisting in the deaths of their patients and will understand the changes made over time to the Hippocratic Oath.

Participants will understand the legal framework in which end-of-life decisions are regulated and considered.

Participants will understand the the strengths and limitations of physician reliance on the Principle of Double Effect to justify their clinical decisions.

Relevance:
Consultation psychiatrists are increasingly being requested to participate in end-of-life decisions, and this symposium presents a clinical, historical, legal, and ethically grounded framework to better understand and answer these questions.

HIV infection is a complex chronic medical illness, and patients infected with HIV require a fully integrated health care team to address a multitude of problems in a coordinated fashion. HIV providers and clinics recognize the need for expert mental health care providers as members of this integrated team, working to assist patients with not only symptom management and psychological reactions to the disease, but with promotion of healthy behaviors necessary for optimal outcomes.

A key factor in the provision of care to patients with HIV is recognition and accurate diagnosis of serious mental impairments that may affect adherence to treatment and outcomes. Although prevalence studies of depression and HIV-associated neurocognitive disorders (HAND) reveal high rates of both disorders, these serious problems often go unrecognized and untreated. Evidence shows that use of screening instruments can improve detection of these disorders in HIV-infected populations, and simple guidelines can assist clinicians in implementing screening protocols for their patients.

Treatment of mental disorders among HIV-infected populations has a positive effect on medical outcomes and quality of life. Recent pessimisms about the treatments available for mental disorders such as major depression have introduced biases into the discussion about integrated health care for HIV. A review of the evidence for the use of antidepressants and a discussion of the limits of the evidence base will promote increased treatment of HIV patients with major depression.

Objectives:

Develop a screening protocol for depressive disorders in HIV-infected populations, and design a plan for full assessment and follow-up.

Create a screening protocol for HIV-associated neurocognitive disorders, and understand the assessment and treatment of HAND.

Demonstrate an understanding of the limitations of the evidence base for treatment of HIV-infected patients with antidepressant medications.

Relevance:
This presentation will be highly relevant to practitioners working with HIV-infected patients, helping them to develop screening and assessment protocols for common major psychiatric comorbidities that affect HIV care.

The world is evolving for many community psychiatrists as collaborating with our primary care colleagues becomes an expectation and responsibility in our daily work. From improving the overall health status of patients with serious mental illness to assisting our primary care colleagues in the detection and appropriate treatment of mental illness in primary care, the opportunity to have a major impact on the lives of patients in both settings presents us with a unique challenge.

Many of us find ourselves utilizing skills from two psychiatric sub-specialty areas as we move between these settings to provide comprehensive collaborative care. These areas of expertise include community psychiatry and consult-liaison psychiatry. This workshop is designed to compare and contrast these two psychiatric subspecialty areas and propose that within the emerging subspecialty arena of integrated care, a psychiatrist with a combination of the two skill sets, a veritable "mash-up", will be most effective. We will start with a comparison of the definitions, skills and competencies in the two areas and go on to provide examples of one urban and one rural program and the skills sets that have been developed by the psychiatrists in these programs to meet their specific needs. The intent of this workshop is to help guide training programs and psychiatrists interested in working in this field to bridge the knowledge gap inherent in new initiatives.

Dr. Rundell will provide an overview and comparison of the two subspecialty areas and describe his work with the DIAMOND project. Dr. Kern will describe his program in Merrillville, Indiana that includes both consultation to a FQHC and the development of an in-house SAMHSA/HRSA grantee site. Dr. Raney will discuss her involvement in a variety of outpatient primary care clinics and the recent opening of a fully integrated health care facility in Cortez, Colorado.

Objectives:

Appreciate the similarities between community psychiatry and psychosomatic medicine.

Understand the evolving skill set for psychiatry needed in the integration of primary care and behavioral health.

Prepare the attendees for working in these integrated settings.

Relevance:
Both community psychiatry and psychosomatic medicine have skill sets vital to the integration of primary care and behavioral health.

Paul Jones, MD, Georgetown University School of Medicine, Washington DC

The field of ethics in pediatric psychosomatic medicine has not been sufficiently addressed. Yet, in the 21st century, the need for bioethical awareness and education of the pediatric psychosomatic medicine (PPM) clinician has expanded due to a number of important developments:

1) The highly technical aspect of medical care has led to complex medical choices requiring a higher level of decision making capacity on the part of the patient and his family.

2) The greater availability of information on medical disease and treatment available to the health care consumer translates into a further level of complexity in the clinician/patient relationship.

3) The PPM clinician consults to a patient population which is increasingly diverse in cultural, religious and ethnic characteristics.

In the pediatric setting, the clinician must grapple with issues of capacity, consent, confidentiality, autonomy/independance, and emancipation and dual agency. In addition, family culture, religion and spirituality must be understood and included in the assessment and intervention. The entire process must be informed by a thorough developmental assessment.

In this workshop, moderated by Dr. Walker, two complex cases in pediatric psychosomatic medicine will be presented by Drs. Tan and Jones. The discussion led by Dr. Dell will focus on the complex bioethical, cultural, and spiritual/religious issues encountered. Audience members will be encouraged to engage in the case discussion.

Objectives:

To improve understanding of bioethical issues in pediatric psychosomatic medicine through case presentation, with an emphasis on cases in which cultural and religious aspects deepen the case complexity.

To present a developmental approach to the assessment of pediatric psychosomatic medicine cases in which bioethical dilemmas are prominent.

To offer a practice approach and curriculum in bioethics in pediatric psychosomatic for use in psychosomatic medicine training programs.

Relevance:
The need for competency in bioethics for psychosomatic medicine clinicians is great and growing due to significant changes in the hospital environment. This workshop broadens participant competency in this area.

Ethical decision making becomes challenging when providing care for those who may benefit from drug therapies they have history of abusing. Clinicians are faced with the challenge of balancing beneficent care aimed at symptom control with the need to prevent harm from substances patients may be unable to use safely. This interactive workshop will explore the ethics of this balance in approaching the suffering of complex medically ill patients at high risk of abusing prescribed substances (“high-risk” patients). Following five brief presentations outlining the ethical and practical challenges unique to a range of high-risk patient populations, case examples will be presented for interactive discussion.

Balancing patients’ right to autonomy and the physicians’ duty to treat patients’ needs is often complicated by real-world practicalities of modern hospital care. Dr. Nicolson will discuss an approach to the ethical issues involved in care of “high-risk” patients in hospital.

Dr. Passik will outline a balanced approach to pain treatment with risk management in “high-risk” patients treated with opioids. Emphasis will be placed on the spectrum of risk, the ethics of employing commonly used risk containment strategies, prescription monitoring programs, urine drug screens, and opioid treatment agreements.

Balancing symptom control with efforts to prevent misuse, diversion, and adverse effects of prescribed substances is one of the most complex challenges in palliative care. Dr. Shuster will present principles for managing the “high-risk” patient in the hospice and palliative care setting, including the challenge of “remote prescribing” through a home hospice agency.

Drug use and abuse in pregnancy exposes two persons to the risk of harm. Dr. Caucci will outline the ethics of safe and effective treatment for pain and anxiety in the pregnant patient, with emphasis on drug safety and decisions to maintain or taper/detox from medications.

Objectives:

Describe the range of challenges faced by clinicians providing care for those who may benefit from drug therapies they have history of abusing.

Outline an approach that balances beneficent care aimed with the need to prevent harm from substances that “high-risk” patients may have problems using safely.

Apply these principles to the care of a range of “high-risk” patients, based on interactive discussion of case examples.

Relevance:
Psychosomatic Medicine clinicians are commonly faced with the challenge of balancing beneficent care with the need to prevent harm to patients at high risk of substance misuse.

Patients with complex medical problems, such as brain injury, neurological illness, and dementia, which produce behavioral issues and agitation, often pose problems for treating teams in the general medical hospital. Consultation-liaison psychiatrists frequently engage in the evaluation and treatment of these patients. These impaired and/or disruptive patients may require daily input from the consultation service. The primary teams often request for transfer to inpatient psychiatry. When a patient's behavioral issues are related to medical illness, transition to inpatient psychiatry may become challenging. Conflicting opinions about the optimal setting for patient management can lead to disagreement between services, and at times, poor outcomes for patients.

We will present and discuss two cases of challenging patients and the issues surrounding their care in the general medical hospital. The issues we will discuss include:

1. What criteria do we use to determine if patients are better managed on medical-surgical floors or on inpatient psychiatry?

2. What are the limitations in management of patients for each setting; psychiatry vs. medical/surgical floor.

3. How do we manage the escalation of violent behavior in a general medical setting?

4. The ethics of involuntary commitment of patients with general medical conditions to inpatient psychiatry.

Objectives:

List factors related to management of difficult patients on the medical-surgical floors and on inpatient psychiatry.

Learn how to implement early interventions to identify and manage patients with brain disease/injury.

Appreciate the controversies involving the ethics of voluntary/involuntary admissions to inpatient psychiatry for patients with general medical conditions.

Relevance:
This presentation is relevant to psychiatrists who treat patietns with complex medical illnesses who display violent or aggressive behavior that may require some discussion of the appropriate setting for treatment.

Scott R. Beach, MD, Massachusetts General Hospital, Boston, MA
"SSRI's and the QT Interval: A Comprehensive Review of the Literature"

QT interval prolongation is a surrogate marker for the prediction of serious adverse drug events including syncope or sudden death in the setting of torsades de pointes (TdP). Antipsychotic agents have been known for decades to have the potential to increase the QT interval and in some cases have been associated with cases of TdP. Though selective serotonin reuptake inhibitors (SSRIs) were felt to be safer medications from a cardiac perspective than older antidepressants, their safety with regards to QT prolongation has been called into question in the past year, following an FDA recommendation limiting the dosing of citalopram.

This symposium will address many of the key issues involving QT prolongation and psychiatric medications. Dr. Noseworthy (Cardiac Arrhythmia Service, MGH) will begin with a discussion of the meaning of the QT interval, optimal methods for measuring the interval, and the association between a prolonged QT interval and lethal arrhythmias such as TdP. Dr. Celano (Fellow in PM, MGH) will then review the data on QT interval prolongation and TdP related to the use of antipsychotic medications, with a particular focus on the use of intravenous haloperidol, as this is the medication most commonly associated with QT prolongation in psychiatric lore. Dr. Beach (Attending Psychiatrist, Psychiatry Consultation and Acute Psychiatric Services, MGH) will next discuss the potential for antidepressants to affect the QT interval, with a particular focus on SSRI's, including a comprehensive review of the literature on QT prolongation with these agents. The latter two presentations will include a specific discussion of the ethical issues involved in decisions regarding the use of psychiatric medications for patients with abnormally long QT intervals and the proper monitoring of their use. Dr. Huffman (Director of Cardiac Psychiatry Research Program, MGH) will serve as a discussant following the three presentations.

Objectives:

Participants will understand the meaning of QT interval, the relationship between the interval and lethal arrhythmias, and how to properly measure the QTc interval.

Participants will be able to identify the concerns associated with the use of antipsychotic agents and antidepressants as they apply to prolongtation of the QT interval and ventricular arrhythmias.

Participants will be better equipped to make ethical decisions regarding the use of these agents in patients who may be at elevated risk for negative cardiac consequences.

Relevance:
Issues involving the use of medications in the setting of a prolonged QT interval arise every day on psychiatry consultation services and represent a key clinical dilemma.

Psychiatric illnesses are prevalent in primary care settings, yet access to and delivery of integrated behavioral health services are often limited in these settings. Integrated psychotherapeutic models are evolving and demonstrate promising outcomes. In this symposium, we will present evidence-based psychotherapies studied in primary care including efficacy data as well as implementation and sustainability barriers and successes.

Dr. Katzelnick will present an overview of psychotherapies studied in primary care and will facilitate discussion between audience members and presenters.

Dr. Kilbourne will present findings from the Life Goals Collaborative Care integrated model for bipolar disorder, describe how the Life Goals psychotherapy program addresses cardiometabolic risk factors, and discuss emerging implementation strategies to further disseminate this program across mental disorder diagnoses in primary care settings.

Dr. Cape will describe implementation of the Improving Access to Psychological Therapies national program in England, its impact on improving access from primary care to evidence-based psychological therapies for anxiety disorders and depression, and developments in the program to enhance integration with primary care medicine.

Dr. Somers will present pilot data from Mayo Clinic's implementation of the Coordinated Anxiety and Learning Management (CALM) program, a primary care-delivered cognitive behavioral therapy program with or without pharmacotherapy for anxiety disorders developed by colleagues at the University of California at Los Angeles and the University of Washington at Seattle.

Objectives:

Learners will be able to identify psychotherapies studied in primary care settings.

Learners will be able to articulate implementation and sustainability barriers for primary care-based psychotherapies and will appreciate strategies for combatting these barriers.

Learners will be able to transfer skills and information learned to their home institutions if interested in implementing psychotherapies in primary care settings.

Relevance:
This symposium fits well in Track 3, integrating primary care and mental health, as it directly addresses evidence-based psychotherapies implemented in primary care settings in the US and UK.

Much effort has been spent formulating an ideal curriculum for psychosomatic medicine fellows. Unfortunately, many of the key concepts of our field cannot be adequately taught in lecture format. This symposium, targeted at trainees and early career psychiatrists, will focus on four areas of psychiatry consultation-liaison training that aren't typically part of the formal didactic curriculum, but all of which are vital to a successful career as a C-L psychiatrist and all of which pose unique challenges to those in the early stages of their careers. We call these "limbic lessons" because they are all emotionally charged issues that touch on the "gritty" and "dirty" aspects of the jobs we do each day. Each presentation will use specific case examples to highlight the salient challenges.

C-L Psychiatrists are often faced with the task of helping primary teams formulate reasonable consult questions and at times explaining to other physicians why certain requests or expectations of consultants are unreasonable. Dr. Beach will discuss various strategies for working with other specialties to maximize the efficacy of consults and minimize service burdens. He will also address the issues of chart confrontations and disputed sign-offs.

Not infrequently, C-L Psychiatrists make medical diagnoses that primary teams may have missed or ignored. Dr. Hartney will address the delicate issue of collaborating with primary teams to encourage further workup or suggest potential etiologies in a non-confrontational way that does not bruise egos.

C-L Psychiatrists are frequently involved in "high profile" media cases or sensationalistic stories. Dr. Gross will discuss the various legal and ethical dilemmas posed by such cases and propose strategies for navigating the often-difficult role of eliciting a history from a reluctant historian.

C-L Psychiatrists often are called to care for teams, families and patients when medical acuity is high and patients are in the hospital for prolonged stays. These patients can be difficult and the team dynamics complex. Dr. Kent will discuss strategies for approaching these complicated cases.

Objectives:

Understand the meaning of a valuable consult and be able to help a team formulate effective consult questions.

Apply concrete strategies for helping the primary team expand the work-up or enhance management.

Navigate "high profile" cases effectively with consideration to unique legal and ethical issues that may arise. Manage the psychiatric complexities of long term high acuity medical cases.

Relevance:
This symposium targets early career psychiatrists focusing on "limbic lessons" learned during psychiatry consultation-liaison fellowship that are often not part of formalized didactics however are a critical aspect of training.

An astounding 50% of patients presenting to internist have issues with sexual health [1,2]. Among married couples, sexual dysfunction complaints are present in 40 percent of men and 63 percent of women [3]. Erectile dysfunction in middle-aged and older men ranges between 16 and 52 percent [6]. Sexual dysfunction diminishes the quality of life and also can be an indication of serious medical problems[12-27], depression [20] and marital discord [28,29]. One of the most commonly prescribed medication groups, selective serotonin reuptake inhibitors (SSRIs), have been reported to reduce libido, interfere with orgasm, and to increase ejaculation latency [1-4]. Given the extent of sexual dysfunction in patients seeking medical care, the side effect burden from treatment for depression and the impact on quality of life, we propose a symposium covering sexual health. Our symposium will focus on four key areas within sexual health.

The symposium will begin with an overview of sexual health by Dr. Baer. Normal physiology, medical history taking and techniques for overcoming clinical anxiety about talking about sex will be reviewed. Newest evidence regarding sexual side effects of SSRIs and treatment options will be presented. Dr. Baer will present results of a survey of patients with cancer detailing patient wishes with regards to sexual health issues they feel should be addressed during and after cancer treatment.

Dr. Hsiao will present an overview of erectile dysfunction (ED). He will detail important aspects of patient's history that are relevant for the consult psychiatrist, discuss reason to refer to urology and provide an overview of treatment options. Currently Dr. Hsiao is involved in treating patients with cancer and he will detail how sexual health may be improved after cancer treatment. Drawing on Dr. Hsiao's experience in treating cancer patients with ED, and his experience running a structured penile rehabilitation program, Dr. Hsiao will discuss how a multidisciplinary approach to erectile dysfunction can improve ED outcomes.

Dr. Meaney-Delman will review gynecologic issues for young women of reproductive age who are undergoing cancer treatments, including a brief description of their options for fertility preservation. Dr. Meaney-Delman will inform the consultant psychiatrist of medical concerns that female cancer patients face and mechanisms to maintain healthy sexual practices during or subsequent to treatment.

Dr. Schwartz will present the current education curriculum for medical students and psychiatry residents with regards to sexual health. Specific opportunities used at Emory University to improve sensitivity in interviewing, multidimensional thinking about sexuality and access to resources for patients with sexual dysfunction will be detailed in the symposium.

Objectives:

Address a deglected aspect of health care and education, intimacy and sexuality.

Inform psychiatrists about options for fertility preservation and treatment of sexual side effects of cancer care.

Improve education of students, residents and fellows with regards to sexual health.

Relevance:
Psychosomatic psychiatrists work with patients who have multiple medical problems which interfere with sexual health. Sexuality is a key feature of intimate relationships and should be addressed.

Psychiatrists are often asked to determine if a patient in the general hospital has "capacity"; however, after that question has been addressed, the question, "So what now?" often goes unanswered. Since current notions of substituted judgment are based on a variety of ethical conceptions of autonomy, this can lead to confusion and disagreement amongst both providers and family members, despite the presence of clear legal standards.

This workshop will clarify current legal standards for the use of substituted judgment and present practical strategies for management. It will also provide an overview of the ethical concepts that ground our thinking about these topics. In addition, we will present core concepts and strategies that may be employed in teaching trainees and colleagues about these important ethical and legal concepts.

Dr. Green will review the philosophical understanding of autonomy as an overriding ethical value in patient care and discuss philosophical dilemmas that arise from this model. She will discuss viable ethical approaches to patient care and provide a practical model for understanding and teaching about complex cases.

Dr. Wei will discuss the legal background for substituted judgment, focusing on the evolution of this legal concept and the criteria for substituted judgment. Clear clinical guidelines for substituted judgment, and the legal framework behind them, will be synthesized into a model that will add clarity to clinical practice and be useful for teaching trainees these core legal concepts.

Many patients fail to designate a substituted decision-maker until issues arise that bring their capacity to decide for themselves into question. Dr. Brendel will discuss how we assess the capacity to designate a substituted judgment-maker, highlighting the legal and clinical issues that arise, and offering a clear conceptual model that will be useful in the management of, and teaching about, these cases.

Although substituted judgment is grounded in a respect for patient autonomy, it can feel like an abandonment of the patient. In complex cases, this can lead to significant disagreement amongst providers and negatively impact patient care. Dr. Kontos will discuss the ethical and clinical grounds for this type of disagreement and provide a practical model for recognizing and addressing it in clinical practice.

Dr. Stern will chair and moderate the panel. He will assist in illustrating the clinical and ethical dilemmas that arise from our conception of substituted judgment through the use of case examples and his experience in the practice of psychosomatic medicine.

Objectives:

Understand the legal grounding and standards for substituted judgment in the general hospital and apply this in clinical practice.

Understand and effectively communicate about the ethical underpinnings and debates that ground much of our understanding of substituted judgment in the general hospital .

Be able to assess a patient's capacity to designate a person to make substituted judgments for them, even when that person may not have capacity to make other decisions.

Training in psychiatry at both the medical student and the residency level lays the foundation for future careers in psychiatry and the subspecialty of psychosomatic medicine. Most medical schools offer the consultation-liaison psychiatry service as a site for both the core psychiatry medical student clerkship as well as for electives. For residents, the ACGME mandates a minimum of two months of consultation-liaison psychiatry/psychosomatic medicine training in a general adult psychiatry residency program. Programs vary significantly in terms of year of training, choices of medical training sites, and the amount of supervision and teaching.

In an effort to better unify and improve both medical students and residents' training in this field, the Academy of Psychosomatics has charged its subcommittees on Residency and Medical Student Education with developing a set of recommendations for training in psychosomatic medicine at each of those levels. This document will represent the first update of the Academy's landmark 1996 Guidelines for Consultation-Liaison Training in Psychiatry Residency Programs. This workshop will provide an optimal setting in which to discuss the Medical Student and Residency Education subcommittees' respective proposals for guidelines as we work towards formalizing the recommendations.

Dr. Funk will present the preliminary guidelines for medical student education as proposed by the Medical Student Education Subcommittee of APM.

Dr. Schwartz will present work from the Residency Education Subcommittee including recommendations for residency training in psychosomatic medicine, including proposed guidelines on the structure of the clinical rotations as well as supervision.

Dr. Zimbrean will present the Residency Education Subcommittee's recommendations on the core skills to be taught on the rotation in Psychosomatic Medicine for psychiatry residents, including medical knowledge, patient care, and liaison with other services.

Objectives:

To describe the varied state of training in consultation-liaison psychiatry/psychosomatic medicine in medical student and residency education

To define potential guidelines for medical students and residents in psychosomatic medicine

To recognize elements important to a successful medical student and resident rotation in consultation-liaison psychiatry/psychosomatic medicine

Relevance:
Excellence in medical student and residency education is imperative to the development and maturation of psychosomatic medicine as a field.

Eating disorders have significant medical and psychiatric consequences and have the highest mortality rate of any mental illness[1]. Practitioners are generally familiar with symptoms of eating disorders (ED), as described in the DSM-IV TR. As providers, we envision our eating disordered patients as young, otherwise healthy, women; 90% of those with eating disorders are female and 95% are between the ages of 12 and 25.8[3].

Our discussion will focus on atypical eating disordered populations, those existing beyond the framework described above. Each portion of this discussion will highlight assessment and treatment options that can be incorporated into our practices to better manage these unique populations.

Dr. Sterenson will describe eating disorders recognized in Type I diabetics, who have a unique form of weight loss readily available; diabulimia, or insulin-restriction is the most common form of eating disordered behavior among diabetic women. Current screening measures focus on symptoms of ED that overlap with diabetic management and fail to assess for insulin omission and restriction. Dr. Sterenson will focus on specialized screening tools as well as treatment and prevention of eating disorders in Type I diabetics. She will emphasize risk factors for the development of the comorbidity as well as associated complications.

Dr. Moore will review ED in pregnancy. She will focus on assessment and treatment, highlighting the psychological struggles pregnancy may pose for women with eating disorders. ED can be associated with pregnancy-related complications and those will be discussed. Effective psychotherapeutic and pharmacologic treatment strategies will be reviewed.

Dr. Sim will describe eating disorders in various medical populations, such as GI patients and those with chronic pain. She will include a discussion of risk factors for developing eating disorders in these individuals and will highlight specialized assessment and management of these complex patients. Several cases will be discussed.

Dr. Chen will discuss eating disorders in the elderly. Advancing age is accompanied by the presence of numerous physiological changes, increasing number of chronic medical co-morbidities, polypharmacy and social challenges that may all contribute to poor appetite. While seemingly able to prepare meals, almost 85% of long-term care, 62% of hospitalized elderly patients, and 15% of community dwelling older adults suffer from malnutrition. Dr. Chen will focus on factors leading to weight loss in the elderly and associated consequences.

To become familiar with presentations of and interventions for eating disorders in atypical populations: type I diabetics, pregnant women, and the elderly

To discuss limitations in current screening measures and to investigate alternative methods for identifying eating disorders in type I diabetics.

To describe eating disorders in medical populations, and to recognize risk factors for, assessment, and managment of these complex patients.

Relevance:
As practitioners of psychosomatic medicine, we see patients of all ages with complex medical histories. Given these variables, it’s important to recognize how identification and treatment of psychiatric illness changes.

This symposium will be presented by members of the work group who have developed the new criteria for psychiatric disorders presenting with predominant somatic symptoms (previously known in DSM-IV as somatoform disorders) for DSM-V. They will give participants a preview of the final version of the DSM-V criteria. The presenters will provide the context to understand why these disorders are as they are in the form of the long journey from DSM-IV to DSM-V and the nature of the development process. The initial aims and aspirations of the work group for DSM-V and the rationale for the final criteria will be outlined. The process and outcome of attempts to achieve compatibility with ICD-11 will also be described.

Participants will have the opportunity to question the work group members about the final diagnostic criteria, the reason for each, and the process of their development.

There will also be discussion of the implications for the practice of psychosomatic medicine.

However, when they emerge into the public dialogue, these issues can generate “more heat than light,” as recently happened with healthcare reform and end-of-life care.

PM psychiatrists have expertise that must be leveraged to inform discussion and policymaking in a rapidly changing healthcare landscape—to shed more “light”. PM psychiatrists have vital perspectives on the complexities of inpatient, outpatient, and overall systems of care.

To shed more “light,” PM psychiatry must grow its research capacity, skills and credibility. Without a strong research base, contributions from PM psychiatrists may be limited to one-off consultations, rather than widely disseminable findings. For instance, much of the “heat” around healthcare reform arose from fears that patients’ end-of-life wishes would not be respected, and that care would be rationed at the expense of the seriously or terminally ill. Evidence about the ethical and psychiatric complexities of end-of-life care, inpatient care of the seriously ill, and hospice care is scant. PM psychiatrists are uniquely qualified to formulate and conduct research examining the ethical, medical, and psychiatric issues that actually affect care of the seriously and terminally ill.

Another example is “moral distress” of physicians and other healthcare providers. Moral distress refers to the feeling of being unable to act according to one’s beliefs in what is right, due to internal or external constraints. Minimal research has examined the causes and consequences of moral distress in physicians, yet one might hypothesize that moral distress could increase if physicians are asked to practice in ways that violate their beliefs—e.g., if they are asked to ration care unfairly. Questions of such weighty moral and ethical significance deserve rigorous study.

This workshop will provide a hands-on experience in how to take the seed of an idea and develop it into a viable research project. Three psychiatrists (Drs. Dunn, Roberts, and Chen) with ethics research expertise will describe their own approach to envisioning and implementing ethics-related research. Workshop attendees will then interact to engage in real-time consultation about their own ideas. Interactive, constructive review of research project ideas at any stage of development will be facilitated. This will also provide an opportunity to seek input from and network with other attendees. The goal is for each attendee to develop an answerable research question and a list of “next action” steps for developing their project.

Objectives:

Apply knowledge and expertise from PM psychiatry to the identification of ethical issues that could be examined empirically.

Develop specific "next action" steps for designing and implementing a research project relevant to ethical issues in PM psychiatry.

Relevance:
PM psychiatrists encounter numerous ethical issues and have unique expertise that can help inform ethically-relevant issues at the medicine-psychiatry interface. Research strategies for examining ethical issues will be detailed.

The transition to practice is a time of great turmoil for many residents and fellows. Many trainees express an interest in having guidance around pragmatic considerations of this transition. However, many existing "transition to practice" curricula or workshops may not adequately answer practical questions for individuals hoping to pursue careers in psychosomatic medicine. In this workshop, we will explore practical issues such as networking and mentoring, CV preparation, career options, how to locate a job, interviewing and negotiation skills, as well as the ever-important work-life balance in the context of the psychosomatic medicine sub-specialty.

The first 20-30 minutes will be spent in large group didactics/discussion and will provide an overview on all of these areas, as well as giving resources as to where to find more information on these topics. Participants will then be given the opportunity to choose between three small groups for more focused discussion:

1. Not Just Surviving, but Thriving: When to Say Yes and How to Say No — Drs. Becker, Byatt, and Worley

2. From Application to Contract — Drs. Rundell, Wichman

3. How to Find Your First Job...and Your Next One — Drs. Hutner, Rackley, and Stern

An early career panelist, as well as mid-to-late career panelist, will co-lead each small group discussion in order to provide depth and a wide range of experience to each discussion, as well as provide ample opportunity for networking. After 30 minutes of small group discussion, participants will rotate to a secondary group of their choosing for an additional 30 minutes, in order to give further exposure to these topics.

During the last 15-20 minutes of the workshop, the small groups will reconvene. Time will be dedicated to questions that arose in small group discussion, as well as providing resources on transition to practice topics for our participants.

Objectives:

Participants will be able to craft an appropriate cover letter and CV, navigate challenging interview situations, and utilize effective negotiation strategies to arrive at an agreeable contract.

Participants will be able to describe different career paths within the field of psychosomatic medicine, as well as resources available to them in locating a job within the field.

Participants will be able to identify their own career and personal goals, prioritize these goals and begin to work towards an action plan to reach their set goals.

Relevance:
The workshop will address common challenges faced early career psychiatrists, including job hunting, successful contract negotiation, and work-life balance, as they enter independent practice.

Delirium assessment and management are core skills for all consultation-liaison psychiatrists. As an altered state of mind, most providers recognize that delirium is frequently frightening and distressing to both patients and families. However, providers often become so focused on identifying the underlying causes and managing the problematic symptoms that the patient's experience of the delirious state may become de-emphasized. Once patients begin to clear the delirium, they are often rapidly moved to other treatment or rehabilative settings, denying the psychiatrist of the opportunity to hear about the patient's recollections and inner experience of this intense period of altered consciousness. Studies have suggested increased rates of Generalized Anxiety Disorder and PTSD following delirium but overall the experience of patients following recovery from delirium is not well characterized.

The experimental film, On a Phantom Limb, depicts the experience of emergency illness, near-death, and resultant delirium to examine the journey of a woman through these phenomena. Combining images and memory of extensive physical and emotional trauma with Frankenstein-like tropes of the risks of re-animation and the unintentional consequences of medical advances, the filmmaker Nancy Andrews creates the confused and submerged states of delirium and their aftermath. Of note, Andrews is a John Simon Guggenheim Fellow in filmmaking (2008). Her work has been presented at festivals, screenings and museums internationally. The Museum of Modern Art has collected six of Andrews' experimental films. Andrews is currently on faculty at the College of the Atlantic where she teaches video making, animation, time-based arts and film studies.

The workshop proposes to present this 35-minute experimental film, followed by a discussion with the patient/filmmaker of her personal experience of delirium and survival of the process. Discussants will include Drs. Summergrad and Sharma, who will focus on the use of art in the representation of illness. Dr. Gitlin will facilitate audience participation around the patient experience of delirium. Primary goal of workshop will be to increase C-L psychiatrists' awareness of, and attention to, the patient's experience of the state of delirium.

Objectives:

Participants will analyze the nature of the patient experience of delirium and similar altered states of consciousness.

Participants will consider the use of film and other medium in the representation of illness and delirium.

Participants will learn approaches to the care of the delirious patient that utilize increased awareness of the patient's internal experience of that state of awareness.

Relevance:
Assessment, management and support of delirious patients is critical to most C-L Psychiatrists. This session will help improve their awareness of the patient experience and thus improve practice.

Keira Chism, MD, Thomas Jefferson University, Philadelphia, PA
"Psychiatry Can Help with That: Early Experiences in a Hospitalist Model of C-L Care Delivery"

The practice of consultation-liaison psychiatry occupies a position not only at the intersection of psychiatry and medicine, but also at the confluence of clinical care and hospital administration. Although psychosomaticists often examine new issues in the knowledge and practice of medicine, they often do not develop an understanding of hospital economics as it relates to C-L service delivery. In our combined community-academic C-L setting we initiated a number of programs specifically aimed at simultaneously meeting the demands of excellent clinical care and evolving financial concerns of the hospital. While optimizing patient care, safety and satisfaction, we also designed programs that minimized FTEs of ancillary clinical staff, decreased length of stay, reduce hospital costs, maximized staff safety, and tracked C-L reimbursement.

For example, the close observation project instituted a criteria checklist for nurses to request close observation. It was associated with patient companion safety training for behaviorally difficult patients, to improve education about, and clinical management of, behavioral emergencies by C-L staff. The creation of a dedicated medical-surgical unit to co-manage and care for patients with complex behavioral and medical issues is a logical outgrowth of our intensive C-L activities. Our communication training program for physicians arises from an understanding that patient satisfaction is intimately tied to the interaction with the physician care provider. C-L psychiatrists, with their experience in working with and guiding difficult clinical encounters, are optimally positioned to help other physicians develop these skills. We will present an overview of the strategies and services provided by psychiatry in a model of full-time, dedicated psychosomaticist hospitalist coverage. Our speakers will describe these initiatives, outline the quality measures used to evaluate their efficacy, and cite the data tracking involved in demonstrating financial benefit to the hospital.

Objectives:

Utilize experience with financial tracking of C-L service benefits to home C-L service.

Understand the variety of ways that C-L services can integrate into hospital administration.

Create new programs for clinical and educational services at home institutions.

Relevance:
We offer examples of unique programs that may help to expand and lead to financial support for the endeavors of psychosomaticists working in a variety of settings.

Lydia Chwastiak MD, MPH, Yale University, New Haven, CT
"Approaches to the Management of Morbid Obesity in Patients with Schizophrenia"

Linda Ganzini, MD, MPH, FAPM, Portland VAMC, Portland, OR
"Delirium and End of Life Care in Patients with Schizophrenia"

Benjamin Druss, MD, MPH, Rollins School of Public Health, Emory University, Atlanta GA
"Emerging Clinical and Policy Models of Integrated Service Delivery for Patients with Schizophrenia and other Severe Mental Illness."

Schizophrenia reduces life expectancy by at least 15 years, and the mortality gap—the gap between the age of death for people in the community without mental illness and those with schizophrenia—has increased over recent decades with disparities of care in disease prevention, symptom assessment and diagnosis, and treatment including palliation. In this symposium, presenters will address new areas of knowledge and innovative approaches to improve medical care among patients with schizophrenia.

Dr. Freudenreich will provide an overview of three infections and their relevance for patients with schizophrenia: tuberculosis, hepatitis C, and HIV/AIDS. His talk will outline the role that psychiatrists can play in the screening for these diseases and in advocacy for treatment in often marginalized patients. In the next decade, many patients with schizophrenia will likely seek treatment for hepatitis C as new treatments have become available.

Dr. Chwastiak will discuss the epidemic of obesity among persons with schizophrenia, and the increased rates of class III (morbid) obesity (BMI > 40 kg/ m2). She will review the literature on the effectiveness of pharmacologic and non-pharmacologic weight management interventions in this population, the clinical assessment of the appropriateness and risks and benefits of bariatric surgery.

Dr. Ganzini will review recent studies about the incidence and correlates of delirium and end of life care in patients with schizophrenia.

Dr. Kim will focus on the capacity of persons with schizophrenia to make decisions about their medical care. He will provide a practical summary of the current literature and a framework for clinicians to use in assessing decision making capacity in persons with both schizophrenia and obesity, terminal illness, or infections.

Objectives:

Discuss the clinical indications, and the risks and benefits of bariatric surgery with their patients with schizophrenia and morbid obesity.

Discuss screening for hepatitis C and HIV/AIDS with their patients with schizophrenia.

Determine decision making capacity of patients with schizophrenia.

Relevance:
Care of patients with both medical illness and schizophrenia is a core skills for psychosomatic psychiatrists,

Emerging evidence suggests that adult presentations of medical disease are strongly influenced by early caregiving experiences. Attachment theory, a model proposed by John Bowlby, provides a way of conceptualizing these early developmental experiences in terms of their psychological and physiological consequence in adulthood. Studies suggest that insecure attachment styles may precipitate neurohormonal changes increasing vulnerability to stress. Moreover, an understanding of attachment style, specifically secure and insecure sub-types, can provide insights into the illness experience of patients and can help guide medical team management of more challenging patient interactions. Studies have also confirmed an association with insecure attachment style and medically unexplained symptoms, depression and poor adherence to medical treatments.

The University of Toronto Consultation-Liaison (C-L) Psychiatry program has adopted attachment theory as a model for understanding and managing patient psychosocial burden and problematic illness behaviors in medical settings. Research on avoidant and anxious attachment style have been examined as predictors of symptoms reporting, health related quality of life and psychological adaptation to medical illness The following symposium will provide an understanding attachment style and the growing research on attachment theory with respect to medical and psychosocial outcomes.

The symposium will begin with an overview of attachment theory in medical settings and clinical implications "at the bedside" (Dr. Hunter). Dr. Maunder will provide a summary of research demonstrating links between attachment and health risk behaviours including smoking and problem drinking. Dr. Blank will review data on the association of insecure attachment styles on somatic symptoms and treatment adherence in patients with chronic liver disease. Dr. Sockalingam will summarize a study examining the effects of attachment style on quality of life in obesity and will explore the role of attachment style in development of obesity. The symposium will conclude with recommendations on how to manage insecure attachment styles in medical settings.

Identify the association between insecure attachment styles and psychosocial and physical burden in patients with chronic medical diseases

Formulate an approach to managing health behaviors that result from insecure attachment

Relevance:
The presentation will illustrate the merits and the clinical relevance of using attachment theory to understand illness behavior and commonly encountered challenging patient encounters in psychosomatic settings.

When persons with severe mental illness refuse medical or surgical treatment, difficult ethical and legal dilemmas may arise. We present three clinical cases exemplifying the complexity of these ethical-legal issues. Disparate interpretations of formal guidelines can further complicate medical and psychiatric care. As psychosomatic medicine psychiatrists, we have an opportunity to educate the staff, mediate conflicts, and improve communication among caregivers. We would like not only to demonstrate the difficulties encountered in our practice in the general hospital setting, but also to underscore the importance of our liaison role to help guide other team members in their decisions when providing medical care to persons with severe mental illness. We review the current literature on published guidelines regarding medical treatment of psychiatric patients who lack medical decision-making capacity. This evidence-based symposium is designed to encourage participation in an interactive discussion of the cases presented by both the panel and participants.

Dr. Salman will discuss a patient recently LPS-conserved for schizoaffective disorder who needed dialysis for renal failure. The legal process to add medical powers to the conservatorship took several weeks, leading to slow deterioration in the patient's medical condition—however, not to the point that it could be considered an emergency, which would have allowed the medicine team to initiate treatment.

Dr. Syed will discuss a patient with history of schizophrenia, acutely psychotic, and refusing treatment for necrotic cellulitis affecting her toes. C-L psychiatry recommends filing for Petition 3200 for a court appointed temporary guardian to assist in medical decision-making. However, Risk Management insists on pursuing a psychiatric (long-term) conservatorship, without giving the patient a chance to regain her capacity with appropriate psychotropic treatment.

Dr. Shim will discuss a patient with chronic schizophrenia, who has advanced cirrhosis and a large aortic aneurysm at risk for imminent rupture, who refuses surgical intervention. The primary team and the psychiatric consultant disagree on the capacity assessment. Similarly, the primary team and the vascular surgery consultant are not in accord in terms of recommendations for appropriate treatment.

Dr. Dadoyan will review the current literature on published guidelines regarding medical treatment of psychiatric patients who lack medical decision-making capacity.

Objectives:

To improve the understanding and appreciation of various ethical and legal dilemmas encountred in medical care of psychiatric patients.

To increase the liaison potential and competence when helping other providers to render the most appropriate care while adhering to ethic and legal mandates.

To facilitate the formation of ethical guidelines in their institution to streamline patients care, interdisciplinary communication and cooperation.

Relevance:
The presentation addresses common ethical-legal dilemmas encountred in a general hospital setting. These dilemmas can create interdisciplinary tensions, complicate and even delay an appropriate medical care for patients.

Patients at risk for suicide are encountered by psychosomatic medicine practitioners in a multitude of settings. Patients in this category may present to the emergency department, and, depending on whether they have attempted suicide, may be admitted to a general care floor. The responsibility of assessment and management of these patients’ risk for suicidal behavior regularly falls to the consulting psychiatrist. Given the shortage of inpatient mental health beds and possible long wait times for transfer to a specialty hospital, a prudent consulting psychiatrist will provide an astute and reasoned assessment and take every effort to minimize risk, perhaps with an eye towards discharging the patient home from the general medical setting, rather than admitting the patient to a psychiatric hospital.

Dr. Ravindranath will present material regarding suicide risk assessment in the emergency department and interventions from this acute setting that may decrease the risk of suicide if the patient is discharged to the community.

Dr. Desan will present material regarding self-injury risk management while the patient is admitted to a general care or ICU ward, including the utility of 1:1 observers and other interventions.

Dr. Scher will present material regarding the utility of ongoing brief psychotherapy while the patient is admitted to the general care floor.

The presenters will field questions from the audience in a panel discussion format.

Objectives:

Understand and be able to implement the elements of a comprehensive suicide safety plan.

Understand the benefits and drawbacks of various steps needed to prevent suicide while the patient is in the acute medical setting.

Understand the utility of psychotherapeutic interventions for reduction of suicide risk while the patient is in the general medical setting.

Relevance:
PSM providers are called upon to assess suicide risk in a variety of settings, including the emergency department and medical ward. We will improve their skill at this task.

Catatonia is clearly under-recognized in psychiatric and probably also in medical patients. Standardized instruments such as the Bush-Francis Catatonia Rating Scale [BFCRS] may aid recognition and monitoring of treatment.

Catatonia is accompanied by significant morbidity and mortality, so treatment is essential, whether by addressing underlying medical and neurological illness or by targeted treatment with lorazepam and ECT which have been useful in ‘organic’ catatonia. Medical complications of severe or prolonged catatonia will be reviewed. Clinical vignettes will be employed throughout this presentation and audience participation encouraged.

Dr. Francis is the co-developer of the Bush-Francis Catatonia Rating Scale and will show numerous video vignettes of actual medical and psychiatric patients with catatonia before, during, and after treatment. Use of these videos with explanatory comments fosters improved clinical skills. Attendees will gain experience using the Bush-Francis catatonia scale to improve detection and quantification of clinical features of catatonia.

Discussion will highlight treatment options for catatonia, including management of underlying systemic/neurological illness in medical patients.

Objectives:

Attendees will recognize three common signs of catatonia.

Attendees will learn the usefulness of a standardized rating scale for catatonia.

Attendees will recognize two treatments for catatonia in medical patients.

Relevance:
Catatonia is under-recognized in medical and psychiatric settings. This workshop will present several video vignettes of real psychiatric and medical patients with catatonia and illustrate assessment and management.

Negotiating for time, support and finances can be daunting, especially for early career consultation psychiatrists. This workshop aims to provide basic knowledge to early career consultation psychiatrists about administrative aspects of running a service, generating and monitoring revenue streams and discovering opportunities for growing the service. We will use personal, hands-on experiences from starting, growing and running consultation services in academic medical centers and community-based hospitals. Panel discussion and small group formats will be used to highlight practical knowledge about gauging service needs, billing and coding to generate revenue, balancing teaching and service, and developing opportunities for expanding consultation services.

Objectives:

Participants will be able to describe basic billing and coding procedures for consultation work.

Participants will be able to describe common areas for service growth within institutions.

Participants will be able to identify critical skills needed for negotiating clinical service commitments and education.

Relevance:
This workshop is geared toward early career psychiatrists to provide practical knowledge and skills about business and administrative challenges in consultation psychiatry. Interested individuals from any career phase are welcome.

Introduction: Four years ago we started an ACGME accredited fellowship in psychosomatic medicine at the University of Pennsylvania and Philadelphia VAMC. Based upon the observation that large tertiary care hospitals rely heavily upon consultations by specialty and subspecialty physicians in nearly all areas of medicine, we chose to design a psychosomatic medicine fellowship that emulated this model by emphasizing training in the following eight subspecialty clinics: Solid Organ Transplantation, OB-Gyn, HIV/AIDS, Neurology, Oncology, Dermatology, Gastroenterology and Anesthesia/Pain. Fellows spend a half-day each week in each clinic for at total of 4.5 months of their fellowship year.

Given that higher acuity patients in general hospital settings are being discharged after shorter and shorter stays, we speculated that by allocating approximately 40% of a fellow’s training time to outpatient subspecialty clinics, fellows would be better suited to provide such specialized services in a private practice or general hospital setting after completing their training. Furthermore, because of the complexity and ever expanding knowledge base required for the many subspecialty areas of medicine that exist today, it seemed logical to embed psychosomatic medicine attendings who possess the expertise and knowledge of that specific subspecialty in that department’s outpatient clinic. Our primary goal was to establish a collaborative model of comprehensive care for fellowship training.

As such, we propose to describe our experiences of having set up and managed these embedded psychosomatic medicine clinics whilst providing supervision and teaching to our psychosomatic medicine fellows. We will engage the audience in a discussion of the following topics:

More than one million people are diagnosed with cancer annually in the United States (1). In 2011, the Commission on Cancer (CoC) accreditation panel issued a mandate requiring universal psychosocial distress screening in all comprehensive oncology centers (2). Due to the relatively few numbers of psychiatrists who specialize in psycho-oncology, all psychosomatic medicine clinicians must increasingly respond to distressed cancer patients with psychiatric presentations. Psychosomatic medicine psychiatrists representing four U.S. comprehensive cancer centers will discuss key issues in psycho-oncology in this American Psychosocial Oncology Society (APOS)-sponsored workshop. Presenters will provide evidence-based updates on assessment and treatment of psychiatric issues across several cancer types (breast cancer; primary brain tumors; hematologic malignancies), selected for their high prevalence and relevance to both inpatient and outpatient psychosomatic medicine settings.

Drs. Park and Meyer will discuss recent evidence pertaining to breast cancer, including the epidemiology of mood/anxiety/alcohol use disorders, patterns of distress according to the phase of treatment, and the effects of adjuvant hormonal therapies such as tamoxifen. Post-chemotherapy cognitive dysfunction (chemobrain) will also be addressed, and data from Dr. Meyer's pilot intervention study in breast cancer survivors will be presented.

Dr. Lynn will present an overview of the management of bone marrow transplant patients, including acute psychiatric complications in the inpatient setting and an approach to pre-transplant assessment, highlighting the social, medical and ethical issues relevant to transplant candidacy.

Dr. Schuermeyer will discuss issues specific to primary brain tumors, such as the management of neuropsychiatric syndromes including abulia and other personality change, cancer fatigue, and ethical issues pertaining to capacity evaluation.

Dr. Vitagliano will moderate the workshop and provide additional commentary.

Manage ethical dilemmas that arise in the course of evaluation for bone marrow transplant and enrollment in oncology clinical trials

Relevance:
Due to the shortage of psychiatrists who specialize in psycho-oncology, all psychosomatic medicine clinicians must increasingly respond to distressed cancer patients with psychiatric presentations.

Women's mental health, a specialty of psychiatry that focuses on the psychiatric issues across the reproductive life span, is a rapidly expanding field. Due to regular contact with health professionals, the perinatal period is an ideal time to detect and treat mental illness. Despite the opportune time and setting, mental illness is under-diagnosed and under-treated and many psychiatrists are hesitant to treat, due to concerns about the potential impact on fertility, pregnancy, delivery, and/or lactation. Psychosomatic medicine specialists are increasingly called upon to evaluate and treat pregnant and postpartum women, in both the inpatient and the outpatient setting. This course will present an update in women's mental health specifically geared toward psychosomatic medicine specialists.

Discussants will provide an update on the evaluation and management of perinatal depression, which is the most common complication of childbirth, as well as bipolar disorder and psychotic disorders. A comprehensive overview of antidepressants, mood stabilizers, antipsychotics, anxiolytics and sleep aids and their use in pregnancy and lactation will be a significant portion of this symposium. Substance use in pregnancy will also be addressed.

Objectives:

The learner will be able to utilize an evidence-based approach to care for a psychiatrially-ill perinatal woman.

The learner will be able to describe the risk and benefits of prescribing psychiatric medications to perinatal women.

The learner will be able to describe the trends and treatment options for substance abuse in pregnant women.

Relevance:
Many psychiatrists are uncomfortable treating perinatal women due to concerns about psychotropic medications and their potential risks to the fetus, pregnancy and delivery complications, and transfer to breastmilk.

The care of immediate post organ transplant patients is unique and challenging. With the exception of kidney transplant, most solid organ transplant patients require ICU admission with varying length of stay after the surgery. Patients are at risk for neuropsychological issues given the nature of procedure as well as the need for immunosuppressant medications. Multiple teams are involved with the care and conflicts among team members and/or patients as well as ethical issues are not uncommon.

Dr. Maldonado will begin with a discussion of the epidemiology of the most common neuropsychiatric symptoms present in the peri-transplantation period (e.g., acute delirium, sedation, anxiety, psychosis, medical PTSD).

Dr. Kissner will discuss medication side effects, relevant drug interactions of immunosuppressive medications, as well as psychotropic agents typically used in the acute post-transplant period. Topics will include P450 interactions, choice of antipsychotics or other agents as needed when asked for consultation, and the ramifications of these complicated post-transplant medication regimens.

Dr. Lolak will discuss common psychological and psychodynamic issues in the immediate post-transplant period. The issues of demoralization and its management will be covered. The relevant psychodynamic topics, including personality types, conflict between patients and team, and among team members from different disciplines will be discussed.

Dr. Sher will round up the symposium with the important ethical and legal issues that arise in post-transplant setting. These will include the conflict and disagreement between the team members and its influence on patient's care; the concept of medical futility in context of multiple and devastating medical complications post-transplant with grim prognosis; and the sensitive topic of when transplant program statistics and patient's quality of life compete. She will exemplify with the ethical issues that arose in the case that opened this presentation.

Objectives:

Recognize the various neuropsychiatric syndromes presenting in the perioperative transplant period.

Understand the most clinically significant medication effects and drug interactions present in the acute post-transplant patient.

Understand and be able to identify important and sensitive psychodynamic, ethical and legal issues that might be inherent in post-transplant setting.

Relevance:
Participation in this symposium will allow the audience to understand the complex psychological, interpersonal and ethical dilemmas, neuropsychiatric syndromes, and pharmacological challenges encountered by posttransplant patients.

This symposium will consider how integrated evidence-based models of care can be implemented; what the obstacles are, and how they have been overcome, with practical examples.

DIAMOND is the implementation of an evidence-based model of collaborative care across Minnesota where research-comparable results on six and twelve month remission rates for depression have been obtained on an on-going basis. Dr. Williams' presentation will describe the model and the methods used to disseminate DIAMOND with a special focus on collaborative spread and readiness for change, the value of a neutral organizer, our choice of outcomes, the reimbursement model, and next steps for achieving successful clinics in the world of healthcare home.

Dr. Unutzer will report on his group's quasi-experimental study of 1,673 depressed adults before and 6,304 after the implementation of a pay for performance (P4P) program with participants who had had high levels of depression, other psychiatric and substance abuse problems and social adversity. Survival analyses of time to improvement in depression before and after P4P found evidence of improvement with a hazard ratio for achieving treatment response of 1.73 (95% CI 1.39 - 2.14). Our analyses strongly suggest that when key quality indicators are tracked and linked to a substantial portion of payment for services, the effectiveness of care can be improved.

TEAMcare is an effective approach to improving both quality of mental health and medical care and the outcomes of depression and medical disease control (HbA1c, LDL and systolic blood pressure) in patients with comorbid depression and diabetes and/or heart disease. Dr. Katon's presentation will describe issues faced by his group's TEAMcare dissemination program. These include developing: a contracting strategy; an effective training package; user friendly treatment manuals; a registry and/or tracking system; advice for different types of organizations regarding billing for TEAMcare services and cost data to help answer questions about return on investment.

Catalyzed by the passage of the Affordable Care Act, there is a growing interest in how to develop and implement behavioral health homes, clinics based in specialty mental health settings that can address the medical needs of persons with serious mental illnesses. Different approaches, with varying benefits and drawbacks, are being developed in clinical settings, demonstration projects, and research studies. Dr. Druss will discuss the different approaches being used, and enumerate the mental health workforce, financing, and organizational issues they raise.